DSM-III

Diagnostic Criteria

A. One or more distinct periods with a predominantly elevated, expansive, or irritable mood. The elevated or irritable mood must be a prominent part of the illness and relatively persistent, although it may alternate or intermingle with depressive mood.

B. Duration of at least one week (or any duration if hospitalization is necessary), during which, for most of the time, at least three of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree.

  1. increase in activity (either socially, at work, or sexually) or physical restlessness
  2. more talkative than usual or pressure to keep talking
  3. flight of ideas or subjective experience that thoughts are racing
  4. inflated self-esteem (grandiosity, which may be delusional)
  5. decreased need for sleep
  6. distractibility, i.e., attention is too easily drawn to unimportant or irrelevant external stimuli
  7. excessive involvement in activities that have a high potential for painful consequences which is not recognized, e.g., buying sprees, sexual indiscretions, foolish business investments, reckless driving

C. Neither of the following dominates the clinical picture when an affective syndrome is absent (i.e., symptoms in criteria A and B above):

  1. preoccupation with a mood-incongruent delusion or hallucinations (see definition below)
  2. bizarre behavior

D. Not superimposed on either Schizophrenia, Schizophreniform Disorder, or a Paranoid Disorder.

E. Not due to any Organic Mental Disorder, such as Substance Intoxication.

(Note: A hypomanic episode is a pathological disturbance similar to, but not as severe as, a manic episode.)

Criteria for subclassification of manic episode

In Remission

This category should be sued when in the past the individual met the full criteria for a manic episode but now is essentially free of manic symptoms or has some signs of the disorder but does not meet the full criteria. The differentiation of this diagnosis no mental disorder requires consideration of the period of time since the last episode, the number of previous episodes, and the need for continued evaluation or prophylactic treatment.

With Psychotic Features

This category should be used when there apparently is gross impairment in reality testing, as when there are delusions or hallucinations or grossly bizarre behavior. When possible, specify whether the psychotic features are mood-incongruent.

Mood-congruent Psychotic Features

Delusions or hallucinations whose content is entirely consistent with the themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person; flight of ideas without apparent awareness by the individual that the speech is not understandable.

Mood-incongruent Psychotic Features

Either (a) or (b):

  • a. Delusions or hallucinations whose content does not involve themes of either inflated self worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions, thought insertion, and delusions of being controlled, whose content has no apparent relationship to any of the themes noted above.
  • b. Any of the following catatonic symptoms: stupor, mutism, negativism, posturing.

Without Psychotic Features

Meets the criteria for manic episode, but no psychotic features are present.

Differential Diagnosis

Organic Affective Syndromes

Organic Affective Syndromes with mania may be due to such substances as amphetamines or steroids, or to some other known organic factor, such as multiple sclerosis. The diagnosis of a manic episode should be made only if a known organic etiology can be excluded.

Schizophrenia

In Schizophrenia, Paranoid Type, there may be irritability and anger that are difficult to distinguish from similar features in a manic episode. In such instances it may be necessary to rely on features that, on a statistical basis, are associated differentially with the two conditions. For example, the diagnosis of a manic episode is more likely if there is a family history of Affective Disorder, good premorbid adjustment, and a previous episode of an Affective Disorder from which there was complete recovery.

Schizoaffective Disorder

The diagnosis of Schizoaffective Disorder may be made whenever the clinician is unable to make a differential diagnosis between manic episode and Schizophrenia.

Cyclothymic Disorder

In Cyclothymic Disorder there are hypomanic periods, but the full manic syndrome is not present. However, in some instances a manic episode may be superimposed on Cyclothymic Disorder. In such cases both Bipolar Disorder and Cyclothymic Disorder should be diagnosed, since it is likely that when the individual recovers from the manic episode, the Cyclothymic Disorder will persist.

DSM-IV

Diagnostic Criteria

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

  1. inflated self-esteem or grandiosity
  2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3. more talkative than usual or pressure to keep talking
  4. flight of ideas or subjective experience that thoughts are racing
  5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a Mixed Episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Specifiers

Severity/Psychotic/Remission Specifiers

These specifiers apply to a Manic Episode in Bipolar I Disorder only if it is the most recent type of mood episode. If criteria are currently met for the Manic Episode, it can be classified as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria are no longer met, the specifier indicates whether the episode is in partial or full remission.

Criteria

Note: Can be applied to a Manic Episode in Bipolar I Disorder only if it is the most recent type of mood episode.

  • Mild: Minimum symptom criteria are met for a Manic Episode.
  • Moderate: Extreme increase in activity or impairment in judgement.
  • Severe Without Psychotic Features: Almost continual supervision required to prevent physical harm to self or others.
  • Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:
    • Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.
    • Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled.
  • In Partial Remission: Symptoms of a Manic Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Manic Episode lasting less than 2 months following the end of the Manic Episode.
  • In Full Remission: During the past 2 months no significant signs or symptoms of the disturbance were present.
  • Unspecified
Mild, Moderate, Severe Without Psychotic Features

Severity is judged to be mild, moderate, or severe based on the number of criteria symptoms, the severity of the symptoms, the degree of functional disability, and the need for supervision. Mild episodes are characterized by the presence of only three or four manic symptoms. Moderate episodes are characterized by an extreme increase in activity or impairment in judgement. Episodes that are Severe Without Psychotic Features are characterized by the need for almost continual supervision to protect the individual from harm to self or others.

Severe With Psychotic Features

This specifier indicates the presence of either delusions or hallucinations (typically auditory). Most commonly, the content of the delusions or hallucinations is consistent with the manic themes, that is, they are mood-congruent psychotic features. For example, God's voice may be heard explaining that the person has a special mission. Persecutory delusions may be based on the idea that the person is being persecuted because of some special relationship or attribute.

Less commonly, the content of the hallucinations or delusions has no apparent relationship to manic themes, that is, they are mood-incongruent psychotic features. These may include persecutory delusions (not directly related to grandiose themes), delusions of thought insertion (i.e., one's thoughts are not one's own), delusions of thought broadcasting (i.e., others can hear one's thoughts), and delusions of control (i.e., one's actions are under outside control). The presence of these features may be associated with a poorer prognosis. The clinician can indicate the nature of the psychotic features by specifying With Mood-Congruent Features or With Mood-Incongruent Features.

In Partial Remission, In Full Remission

Full Remission requires a period of at least 2 months in which there are no significant symptoms of mania. There are two ways for the episode to be In Partial Remission: 1) symptoms of a Manic Episode are still present, but full criteria are no longer met; or 2) there are no longer any significant symptoms of a Manic Episode, but the period of remission has been less than 2 months.

Differential Diagnosis

Mood Disorder Due to a General Medical Condition

A Manic Episode must be distinguished from a Mood Disorder Due to a General Medical Condition. The appropriate diagnosis would be Mood Disorder Due to a General Medical Condition if the mood disturbance is judged to be the direct physiological consequence of a specific general medical condition (e.g., multiple sclerosis, brain tumor, Cushing's syndrome). This determination is based on the history, laboratory findings, or physical examination. If it is judged that the manic symptoms are not the direct physiological consequence of the general medical condition, then the primary Mood Disorder is recorded (e.g., Bipolar I Disorder) and the general medical condition is recorded separately (e.g., myocardial infarction). A late onset of a first Manic Episode (e.g., after age 50 years) should alert the clinician to the possibility of an etiological general medical condition or substance.

Substance-Induced Mood Disorder

A Substance-Induced Mood Disorder is distinguished from a Manic Episode by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the mood disturbance. Symptoms like those seen in a Manic Episode may be precipitated by a drug of abuse (e.g., manic symptoms that occur only in the context of intoxication with cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Manic Features, With Onset During Intoxication). Symptoms like those seen in a Manic Episode may also be precipitated by antidepressant treatment such as medication, electroconvulsive therapy, or light therapy. Such episodes are also diagnosed as Substance-Induced Mood Disorders (e.g., Amitriptyline-Induced Mood Disorder, With Manic Features; Electroconvulsive Therapy-Induced Mood Disorder, With Manic Features).

Hypomanic Episodes

Manic Episodes should be distinguished from Hypomanic Episodes. Although Manic Episodes and Hypomanic Episodes have an identical list of characteristic symptoms, the disturbance in Hypomanic Episodes is not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization. Some Hypomanic Episodes may evolve into full Manic Episodes.

Major Depressive and Mixed Episodes

Major Depressive Episodes with prominent irritable mood may be difficult to distinguish from Manic Episodes with irritable mood or from Mixed Episodes. This determination requires a careful clinical evaluation of the presence of manic symptoms. If criteria are met for both a Manic Episode and a Major Depressive Episode nearly every day for at least a 1-week period, this would constitute a Mixed Episode.

Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder and a Manic Episode are both characterized by excessive activity, impulsive behavior, poor judgment, and denial of problems. Attention-Deficit/Hyperactivity Disorder is distinguished from a Manic Episode by its characteristic early onset (i.e., before age 7 years), chronic rather than episodic course, lack of relatively clear onsets and offsets, and the absence of abnormally expansive or elevated mood or psychotic features.

DSM-5

Diagnostic Criteria

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
  7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. (Note: A full manic episode that emerges during antidepressant treatment [e.g., medication, electroconvulsive therapy] but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.)

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